I recently read news that really brought home the real-life impact on patient care —really, on patient’s lives—of an effective prior authorization (PA) process. In February 2019, long-time disability rights activist and attorney Carrie Ann Lucas died prematurely at age 47 from a plethora of health problems, exacerbated by her disabilities.

However, according to a post following her passing on her Facebook page, her friends and family identify the root cause as the denial by her insurance carrier of “the one specific inhaled antibiotic that she really needed. She had to take a less effective drug and had a bad reaction to that drug. Read the full article.

In the February issue of Primary Care Optometry News, an optometrist who utilizes PARx in his practice was interviewed about his experience with the prior authorization (PA) process – and what best practices he would recommend. “Prior authorizations are here to stay,” Jeffrey S. Williams Jr., OD, Dipl ABO, noted in the article. “Optometrists must learn how to navigate prior authorizations in order for their patients to receive the branded medications they are prescribed.”

Williams, who practices on Long Island, New York, recommends use of a full-service PA process provider to any medical practice struggling with the challenge of PA. His office uses PARx Solutions.

Before adopting the service, navigating PA in his office was messy, Williams said. “It was a lot of blank forms from the 10 different, respective insurance companies that we accept. You’d have to fill it out, fax it and pray that it was approved. If it wasn’t approved, you’d get a 15-page fax back,” he said.

His staff would manage lengthy spreadsheets to keep track of patients, various dates and follow-up milestones. “It was a lot of wasted time and frustration,” Williams said.

Williams outlined how practice owners can assess the impact of the PA process on their practice and weigh the systems available that are intended to help. He wrote that a good starting point is looking at the individual PA process challenges at the practice. These may include:

How important is it for your patients to receive the specific medication that you originally prescribed?

Next, he suggested appraising the current burden on the optometrist and staff in managing PAs:

How many hours are spent on PAs including: hunting down the correct form, completing and submitting the forms and spending time on the phone with managed care plans?

How often are submitted PAs denied by the plan?

If denied, how often does your practice appeal the decision with the plan?

Finally, he suggested considering the PA process options: using a form-based service, or ideally, a full-service provider, per his experience with PARx.

Providers also have the option of going it alone, which Williams says may require a member of the staff focusing solely on PAs or carving out time from multiple staff members. After using the service, not only are approvals accomplished faster at his office, but through the experience, his staff has learned many of the protocols for the different insurance requirements.

“It went from chaos and confusion and shooting in the dark to seeing more patients daily,” Williams said of his practice’s transition to full-service PA provider PARx Solutions.

As pharmaceutical marketing has evolved from “selling pills” to assuring that medications actually get dispensed and taken by patients, many brands have layered patient engagement and support programs into the marketing mix to assist with a range of issues including patient education, therapeutic support, benefit verification, financial assistance, and adherence support. Many brands utilize a patient support program (sometimes referred to as a “patient hub”) as a single point of contact for patients to access these support services online or via 800 numbers. Beyond receiving general product/condition education prior to therapy initiation, patients frequently use these support programs to verify insurance coverage, understand whether prior authorization is required, obtain co-pay cards, or explore the potential availability of Medicare tier exceptions.

While patient support programs often claim to address patient access issues such as PA, they usually fail to result in high physician submission and approval rates. After performing a patient-specific benefit verification and determining that a PA is required, the typical action is to fax a PA form to the prescriber. Similarly, if the patient is covered by Medicare and might be eligible for a lower co-pay from a tier exception (TE), they typically fax the Medicare Coverage Determination form to the practice. In either case, practices frequently do not follow through on the PA or TE request due to the burdensome submission and follow up process required by the managed care (or Medicare) plan. As a result, the PA doesn’t get submitted and the patient gets switched to an alternative therapy or abandons treatment altogether.

One brand utilized an innovative program to drive more prescriptions by integrating a full-service PA support program based on the result of their benefit investigation. Prior to implementing this new program, the brand reported that physician PA submission rates were very low and when a PA was submitted, approval rates averaged around 50-60 percent.

Results. After implementing the new program, the brand saw significant increases in both PA submission and approval rates. Physicians submitted PAs more than 50 percent of the time after receiving a notification from the service provider. Over 42 weeks, physicians submitted a total of 952 PAs independently (without receiving any notifications). After receiving notifications, physicians submitted an incremental 4,967 PAs, with a 75 percent average approval rate.

Overall, the program resulted in nearly 4,000 incremental approved PAs, which translated into approximately 10,000+ incremental TRx’s. The brand’s return on investment in the program was sixteen to one, and more importantly, approximately 4,000 patients ended up receiving the medication their physician deemed best, instead of a substitute therapy or abandoning therapy altogether.

When left on their own, many practices will not deal with the cumbersome process of completing and submitting PAs. A service that makes this process more streamlined and less time consuming for physicians and their staff will lead to higher PA submission rates and more prescriptions dispensed.

Many pharma brands have already created patient support programs that address patient coverage issues. Adding an effective PA service can be a small incremental step that yields large benefits from more patients on therapy, less physician frustration, and fewer prescriptions being substituted or abandoned.

Pharma brands invest heavily in sales and marketing tactics aimed at convincing physicians to prescribe their product. Even when successful, these efforts represent only a first step in realizing more prescriptions that actually get dispensed. Particularly when a prescription requires prior authorization (PA), retail pharmacy data shows that the originally prescribed product ends up being dispensed less than thirty percent of the time. In two-thirds of cases, the medication is either switched to another product or abandoned altogether, leaving both patients and physicians frustrated. PA requirements are being implemented by payers for more brands across most therapeutic categories, so the negative impact on pharma continues to deepen. Read the full article

Recently, PARx expanded our partnership with ZappRx, a healthcare technology company that reduces the administrative burden associated with prescribing specialty medications. As of June 2018, ZappRx users – which range from large academic medical centers to small, independent physician practices – can access PARx Solutions’ prescription prior authorization services across all treatment areas supported on the ZappRx platform. This is especially good news for practices in Gastroenterology, Rheumatology, Cardiology, and Neurology, broadening their ability to significantly shorten the prior authorization timeline. ZappRx leverages our PASS (prior authorization support system) to alleviate the administrative burden for medical practices.

As I noted in the announcement of this expanded partnership, since the beginning, ZappRx and PARx Solutions have been very complementary. We believe that ZappRx offers specialty drug prescribers a comprehensive solution that makes it dramatically easier for physicians to combat and treat complex diseases. Together, we have been tremendously successful in the past 18 months within the Pulmonary Arterial Hypertension (PAH), Idiopathic Pulmonary Fibrosis, and Cystic Fibrosis (CF) therapeutic categories, adding support this year for Congestive Heart Failure and Hyperlipidemia. We are excited to extend our joint solutions into new therapeutic categories, which will immediately and dramatically increase the number of lives we can positively impact.

And it’s already working: according to a ZappRx’s pre-implementation survey results, physicians who prescribed specialty drugs experienced PA approval rates below 75 percent before using the integrated ZappRx -PARx approach, In contrast, the ZappRx-PARx solution has produced approval rates of 95 percent, with approvals secured in a matter of days, not weeks, even for complex conditions such as PAH.

At a recent launch of the ZappRx Platform at a prestigious academic medical center, prescribers were thrilled to have the first PA submitted through the Platform approved the same afternoon. ‘The clinical staff was so surprised at the quick turnaround, that they actually reached out to our team to see if we were playing a joke,’ said Karen Tirozzi, Vice President of Solutions at ZappRx. PARx is excited about continuing to expand our partnership with ZappRx and look forward to providing PA support services to new health care organizations and physicians who choose the ZappRx platform for their specialty drug prescribing support.

I’m not alone in my assessment of the prior authorization (PA) process as a significant burden for physician practices: according to a 2017 American Medical Association (AMA) Prior Authorization Physician Survey,1 a medical practice completes an average of 29.1 PA requests per physician per week, which takes an average of 14.6 hours to process, or nearly two business days.

The PA burden is currently a reasonable one for my staff and I, but that wasn’t always the case. When we handled PAs ourselves – specifically, I handled many submissions personally – the process had a significant, negative impact on practice management and on patient care. No matter how well I kept up with the forms specific to each patient’s insurance plan, their condition, and the medication brand, I’d often find myself facing a denial and so having to get on the phone with the plan. This invariably meant at least 45 minutes on hold – sometimes that long just to reach a person, and not always the right person at that, and with no guarantee I’d be able to turn the denial around. Critical delays were common, and absolutely impacted patient care – for example, I often prescribe Restasis for chronic dry eye, for which there really isn’t an equal substitute, and which requires a PA under most plans.

When PAs are denied, this means my patients aren’t receiving the medication I’ve deemed best suited to treat their condition, which in turn impacts clinical outcomes. I’ve since changed how my practice handles PAs – I now submit via the PARx Solutions portal, knowing I’ll be provided with the right form and that most importantly, as a full service provider the PARx team will work with my patients’ plans on my practice’s behalf. Unlike PA services that provide just the forms, their team of qualified healthcare professionals call the plans (and wait out the inevitable hold times), work with my staff to provide any additional information that is required, and overall greatly increase the potential for approvals. Submissions take an average of 5 minutes to complete, and we usually have a final answer from the plan within 48 hours.

My practice management has improved, my patient care has improved (both in terms of being better able to get the medications I prescribe to my patients, and in the additional time I now have to spend with my patients), and overall, I’d recommend this approach to any medical practice.

Dr. Jeffrey Williams is an Optometrist with Sound Vision Care, Inc. of Long Island, NY. A graduate of The Ohio State University, he is Board Certified by The American Board of Optometry and The National Board of Optometric Examiners.

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For many pharmaceutical brands, managed care restrictions put tremendous pressure on the ability for patients to access prescribed medications, even when their physicians deem a particular medication to be best suited to treat their condition. To combat this challenge, many brands have engaged third parties to implement programs designed to assist physician practices with managing the cumbersome prior authorization (PA) process. While these programs may help generate higher PA approval rates, this metric alone is insufficient in evaluating whether the program is truly beneficial to patients and impactful for the sponsoring brand. Read the full article